A Review Paper Abstract

A Review Paper
Partial Tears of the Anterior Cruciate
Ligament: Diagnosis and Treatment
Fotios Paul Tjoumakaris, MD, Derek J. Donegan, MD, and Jon K. Sekiya, MD
Abstract
In sports medicine, diagnosis and treatment of partial
tears of the anterior cruciate ligament (ACL) continue
to be difficult. Partial tears of the ACL are common,
representing 10% to 28% of all ACL tears. As our understanding of the anatomy of the native ACL improves,
our accuracy in diagnosing these injuries increases.
The advent of magnetic resonance imaging (MRI) and
recognition of injury patterns have more clearly delineated the pathoanatomy in a majority of these cases.
Natural history studies following patients with these
injuries have demonstrated that fewer than 50% of
patients return to their preinjury activity level.
Several studies have also documented that progression to complete rupture is a common outcome for
patients who want to return to an active lifestyle.
Treatment options include conservative modalities (eg,
activity modification, functional rehabilitation, functional
bracing) and surgery (eg, thermal shrinkage of remaining ACL, complete reconstruction, newer techniques
to augment or reconstruct the damaged portion of the
native ligament). Studies comparing conservative treatments with more aggressive operative interventions are
required to fully evaluate the efficacy of these treatments.
A
The natural history of complete ACL ruptures has
been well defined and often reported in the literature.5,6
Typically, patients who sustain a complete ACL tear
report symptomatic instability with pivoting sports
or strenuous activity. Patients diagnosed with partial
tears of the ligament have a less predictable outcome.
Although many continue to experience instability,
many do not, and identifying both groups can be challenging. In addition, diagnosing partial tears and tailoring treatment to individual patients can be difficult, as
there are no clear treatment guidelines.
In this review, we focus on ACL anatomy, diagnosis
and treatment of partial ACL tears, and outcomes and
new treatment techniques.
Anatomy of the ACL
The two-bundle concept of the ACL was introduced
by Palmer7 in 1938 and expanded on by Girgis and colleagues8 in 1975. Each described the ACL as having an
anteromedial (AM) component and a posterolateral (PL)
component on the basis of the insertion of each individual bundle into the tibial surface. In 1991, Amis and
Dawkins9 further elucidated that the ACL has an intermediate (IM) bundle with anatomical and biomechanical
properties very similar to those of the AM bundle. The
nterior cruciate ligament (ACL) injuries are
common. An estimated 80,000 to 250,000
ACL injuries occur yearly, with the majority of
these in athletes between ages 15 and 25.1,2 The
Centers for Disease Control and Prevention3 estimated
that approximately 100,000 ACL reconstructions are
performed annually in the United States. Partial tears
of the ACL, though not as common as complete tears,
may account for 10% to 28% of all ACL injuries, but the
epidemiologic data regarding this entity are not as clearly
defined.4
Dr. Tjoumakaris is Assistant Professor, and Dr. Donegan is
Resident, Department of Orthopaedic Surgery, University of
Pennsylvania, Philadelphia, Pennsylvania.
Dr. Sekiya is Associate Professor, Department of Orthopaedic
Surgery, University of Michigan, Ann Arbor, Michigan.
Address correspondence to: Derek J. Donegan, MD, Department
of Orthopaedic Surgery, Hospital of University of Pennsylvania,
2 Silverstein Building, 3400 Spruce St, Philadelphia, PA 19104
(tel, 215-662-3340; fax, 215-349-5128; e-mail, derek.donegan@
uphs.upenn.edu).
Am J Orthop. 2011;40(2):92-97. Copyright Quadrant HealthCom
Inc. 2011. All rights reserved.
92 The American Journal of Orthopedics®
Figure 1. Sagittal magnetic resonance imaging shows focal
increased signal intensity within substance of anterior cruciate
ligament. Patient had acute partial tear of anterior cruciate ligament compromising anteromedial bundle, with intact posterolateral bundle (see Figure 2).
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F. P. Tjoumakaris et al
Figure 2. Arthroscopic picture of partial anterior cruciate ligament
injury. In this patient, posterolateral (PL) bundle was intact, and
anteromedial (AM) bundle was torn and scarred within notch.
Figure 3. Arthroscopic picture of partial anterior cruciate ligament injury. In this patient, anteromedial (AM) bundle was intact,
and posterolateral (PL) bundle was avulsed off femur.
ACL has a microstructure of collagen bundles of multiple
types (predominantly type I) and a complex matrix of
proteins, glycoproteins, glycosaminoglycans, and elastic
systems.10 On the macroscopic level, the ligament originates on the lateral femoral condyle and courses obliquely
through the knee joint lateral and posterior to medial and
anterior, inserting into a broad area on the tibial plateau.
The cross-sectional diameter of the ligament varies along
its course, from 44 mm2 at the midsubstance to nearly 3
times that at the origin and the insertion.11,12 Total ligament length is 31 to 38 mm and can vary by as much as
10% during normal knee range of motion.13 The ACL is
innervated by posterior articular branches of the tibial
nerve and receives most of its blood supply from branches
of the middle geniculate artery.
The dual-bundle anatomy of the ACL has biomechanical and clinical implications and may provide insight
into the precise pathoanatomy of partial ACL tears. In
a biomechanical study, Gabriel and colleagues14 found
that the PL bundle is tightest in extension and relaxes
as the knee is flexed, and the AM bundle is relaxed in
extension and tightens as the knee approaches 60° of
flexion. In a cadaveric study, all specimens demonstrated the dual-bundle anatomy; in addition, the motion
pattern of the ACL demonstrated that the AM and PL
bundles are oriented parallel with the knee extended and
twist around each other as the knee is flexed.15,16 These
anatomical and biomechanical dynamics may affect the
ligament while it is being injured. Depending on the
flexion angle of the knee and the force applied, there is a
different strain produced within each component of the
ACL, and this strain may produce a partial ligamentous
disruption of the AM bundle, the PL bundle, or both.
history, physical examination findings, imaging studies,
and routine orthopedic follow-up.
Diagnosis of Partial ACL Tears
Diagnosis of partial ACL tears can be challenging. Often,
clinical examination findings can be subtle, and radiographic studies may not reveal significant pathology. The
most accurate diagnosis is achieved by integrating patient
www.amjorthopedics.com Patient History
ACL injuries typically occur in patients who participate
in activities that require running, jumping, or cutting. The
classic scenario is a young athlete who sustains a noncontact pivoting injury while the foot is planted and the knee
is slightly flexed. The ensuing injury may be characterized
as a “pop” or buckling of the knee with eventual swelling from a traumatic hemarthrosis. The history from a
partial disruption of the ACL can be as classic as the
scenario presented, or more nebulous in presentation.
Some patients remember a specific traumatic event, as in
a complete tear, but many others report a minor event in
which the knee felt as if it shifted or rolled. Some patients
report they returned to competitive play later that same
game or within a week after being injured. In rarer cases,
patients report minor pain with certain activity but report
no specific injury. Perhaps one of the most important
components of taking the history is to ask the patient
about the degree of morbidity from the injury and about
similar injuries that may have occurred since the sentinel
event. In addition, the patient should be asked about any
prior treatment for the problem and about the success of
that treatment.
Physical Examination
The physical examination is very similar to that for most
knee injuries. The knee is first inspected for any bruising
or contusion that may indicate a more serious injury. The
knee is checked for an effusion. If one is present, causing discomfort that impedes the physical examination,
it should be aspirated. (Maffulli and colleagues,17 who
performed a study involving 106 athletes who each presented with an acute hemarthrosis of the knee, found that
the ACL was partially disrupted in 28 of these patients
and completely ruptured in 43, as determined by arthroscopy.) Range of motion is assessed. Limited motion may
February 2011 93
Partial Tears of the Anterior Cruciate Ligament: Diagnosis and Treatment
Figure 4. Anatomical reconstruction technique. Tunnel dilator
exited tibial tunnel for posterolateral (PL) insertion.
Figure 5. Femoral tunnel was drilled for posterolateral graft.
Anteromedial (AM) origin on femur visible just posterior to posterolateral (PL) tunnel.
indicate concomitant meniscal pathology, though this is
not a common finding with partial ACL tears. Locking
of the knee or a block to extension may be the result
of interposition of a partial ACL tear (as was observed
by Chun and colleagues18; Finsterbush and colleagues19
found locking in a significant number of patients with
partial ACL tears, the majority resulting from fat pad
adhesion and fibrosis to the damaged stump). The knee
is then examined for any tenderness or swelling along the
joint line. The ligamentous examination is performed,
and its findings compared with those of the contralateral
extremity. The knee is first checked for varus or valgus
instability at both 0° and 30°. The Lachman and pivot
shift test are then performed. It is important to determine whether the patient is guarding or contracting the
hamstrings, which could hinder detection of any subtle
differences. Seldom do patients have a positive anterior
drawer test, as the secondary stabilizers (medial meniscus
and posteromedial corner) are usually preserved with this
injury. The examination may conclude with the KT-1000
(or KT-2000) arthrometer test and comparison of its
finding with that of the unaffected extremity. (Liu and colleagues20 evaluated the KT-2000 test with varying degrees
of ACL disruption, ranging from mild, or a half-tear of
one bundle, to severe, or a complete tear of one bundle
and half of another, and found that mild and moderate
injuries produced only small changes in the anterior tibial
translation at different force levels.) A normal KT finding
does not preclude an injury to a portion of the ACL and
is no substitute for a good physical examination. To date,
no study has correlated the degree of tibial translation or
disruption of the ACL with functional status or need for
operative intervention.
eral view of the involved knee, and bilateral merchant
or sunrise views. All radiographs are inspected for softtissue swelling, effusion, fracture, and overall alignment.
Paramount to determining prognosis is examining for
joint space narrowing that may be indicative of degenerative changes. Any patient with evidence of knee arthrosis
is further studied with a long cassette film to determine
alignment.
In patients with suspected complete or partial ACL
tears, obtaining magnetic resonance imaging (MRI) of
the knee is customary. MRI is also useful in detecting
any chondral injury or meniscal pathology. For accurate diagnosis when partial tears are suspected, often
it is necessary to review the MR images with an experienced musculoskeletal radiologist. In a recent MRI–
arthroscopy comparison study, Duc and colleagues21
found that 4 partial tears were incorrectly diagnosed
by MRI, and the authors concluded that paracoronal
images may be useful in equivocal cases. Earlier, Umans
and colleagues22 found that MRI may not be sensitive
enough to accurately diagnose partial ACL tears; in this
scenario, the sensitivity of MRI was .4 to .75, and the
specificity was .62 to .89. Lawrance and colleagues23
found that, compared with arthroscopy, MRI diagnosed
only 1 of 9 partial ACL tears.
Some investigators have attempted to determine
ways to increase the diagnostic accuracy of conventional imaging. Adding oblique coronal images to the
standard knee MRI and using a 4-point grading scale
for ACL injuries (intact, low-grade partial, high-grade
partial, complete tear) were found to significantly
increase diagnostic accuracy.24 Chen and colleagues25
delineated criteria that assist clinicians in making accurate diagnoses and found that an empty notch sign, a
wavy ACL, a bone contusion, and posterior horn of the
lateral meniscus tears are suggestive of complete ACL
injury. A residual straight and tight ACL fiber seen on
at least one image and a focal increase in ACL signal
intensity in the acute setting are suggestive of partial
Imaging Studies
Plain radiographs are routinely used to look for associated pathology (all patients) and to document status
of the physes (adolescents). Radiographs include bilateral anteroposterior flexion weight-bearing views, a lat94 The American Journal of Orthopedics®
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F. P. Tjoumakaris et al
Figure 6. Posterolateral (PL) graft was passed, and anatomical
augmentation procedure for partial anterior cruciate ligament
disruption was complete.
ACL tears (Figures 1, 2). Studies also have shown that
a lateral bone bruise is highly suggestive of an ACL
injury. Murphy and colleagues26 found that only 1 of
6 patients diagnosed with a partial ACL tear by MRI
had a bone contusion. Zeiss and colleagues27 found that
12% of partial ACL tears were accompanied by a bone
contusion on MRI, whereas 72% of complete ruptures
had this finding; in addition, 80% of the partially torn
ACLs with a bone contusion went on to complete rupture within 6 months after the study date. These findings
provide some prognostic signs that may assist orthopedists in determining appropriate treatment.
Treatment
Nonoperative Treatment
Treatment of partial ACL tears depends entirely on
making an accurate diagnosis and determining degree of
impairment. For some patients with partial tears, little
morbidity is associated with the injury, and knee stability may be adequate for participation in sports and for
all activities of daily living. Treatment in this scenario is
largely supportive: recommending that the patient take the
time to recover from the initial injury and, after rehabilitation, to make a gradual return to sport. Assessing which
patients require more aggressive treatment can be challenging. Various factors are taken into consideration: age,
activity level, degree of laxity on physical examination,
associated injuries, and symptomatic instability. Most
clinicians would agree that symptomatic and debilitating
instability requires a more aggressive approach, likely in
the form of operative intervention. Unfortunately, most
patients with a partial ACL tear fall on the opposite end
of the continuum from complete ACL rupture, with more
subtle physical examination findings, and may not have
effusion, laxity, or other significant findings on examination. Counseling patients in this regard can be difficult,
and a literature review revealed conflicting outcomes in
the natural history of this injury.
www.amjorthopedics.com Odensten and colleagues28 prospectively followed 21
patients with partial ACL tears for 6 years and found
that only 3 ACLs were unstable at most recent followup, with all patients achieving good or excellent results.
They concluded that the course of a partial tear is
benign and that long-term results are good. Sommerlath
and colleagues29 evaluated 22 acute partial ACL tears,
3 of which were repaired initially, and found at longterm follow-up (9-15 years) that no patient required
ACL reconstruction. All 22 patients had decreased
their activity level, and more than half showed signs of
osteoarthritis. The study authors concluded that conservative treatment is effective for this condition. Buckley
and colleagues30 evaluated 25 patients with partial ACL
tears at intermediate follow-up and found that 60%
had good or excellent results. Only 44% of patients had
resumed sports at their preinjury levels; 72% reported
activity-related symptoms. There was no correlation
between ultimate outcome and percentage of ligament
tear at arthroscopy, length of follow-up, or age at injury.
In perhaps one of the best long-term studies, Bak and
colleagues31 followed 56 patients with isolated partial
ACL tears for a mean of 5.3 years. Sixty-two percent
of patients in this series reported good or excellent knee
function; however, only 30% of patients resumed their
preinjury activities. Barrack and colleagues32 reported
on a series of 35 patients with partial tears and found
that 52% had good or excellent results, significantly
better than the natural history of complete ruptures in
the series. Fritschy and colleagues33 found that 18 of 43
patients with partial ACL tears progressed to complete
rupture by 5-year follow-up. Noyes and colleagues34
reported similar results in their series: 38% of patients
with partial tears progressed to complete rupture. The
authors also identified several risk factors for tear progression: degree of initial tear, subtle increase in anterior
translation, and reinjury with giving way.
Our integrated approach to managing a partial ACL
tear is to discuss the risks for complete rupture and give
patients an opportunity to pursue an initial course of
nonoperative treatment. There have been no studies of
the efficacy of bracing or neuromuscular proprioceptive
rehabilitation in preventing complete rupture within the
setting of a partial ACL tear. Mandelbaum and colleagues35 recently found an 88% reduction in noncontact
ACL injury at 1 year and a 74% reduction at 2 years with
a preventive rehabilitation program in female soccer athletes. Although this study and studies like it are aimed at
preventing an initial complete ACL rupture, they could
have implications for preventing a complete tear in the
setting of a partial ACL tear. A functional knee brace is
often prescribed to restore the athlete’s confidence, but
Swirtun and colleagues36 found no objective evidence
supporting use of a brace in patients with acute ACL
tears. At short-term follow-up, however, patients in that
study reported a sense of increased stability wearing the
brace. Earlier, Kocher and colleagues37 found fewer subFebruary 2011 95
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Partial Tears of the Anterior Cruciate Ligament: Diagnosis and Treatment
sequent knee injuries in braced professional skiers than
in nonbraced professional skiers.
Future nonoperative interventions may be aimed at
identifying patients who can cope with partial (or complete) tears of the ACL. In a recent review, Herrington
and Fowler38 concluded that laxity measurements and
International Knee Documentation Committee (IKDC)
ratings are incapable of predicting the functional status
of the ACL-deficient patient. Lysholm-Gillquist scores,
Knee Outcome Survey–Sports Activity Scale (KOSSAS) and Activities of Daily Living Scale (KOS-ADLS)
scores, and Global Knee Function scores are better
tools for distinguishing ACL copers from noncopers.
It is anticipated that, with more clinical studies, we will
become better at identifying patients who can cope with
partial ACL tears, and perhaps we will be able to offer
more aggressive treatment to patients who cannot cope.
Operative Treatment
When conservative management fails and patients continue to experience instability, operative intervention is
often required. Partial tears that progress to complete rupture are routinely treated with standard ACL reconstruction. There is debate as to which management strategy is
optimal for cases in which some ACL fibers remain. In a
majority of patients, intermediate- and long-term failure
rates for repair of completely or partially torn ACLs have
been high.39 There has been recent interest in enhanced
primary repair, a technique that uses biological scaffolds
to enhance primary repair, but the in vivo success of this
technique is still being investigated.40 Steadman and colleagues41 reported good results with use of the healing
response technique in skeletally immature patients with
complete ACL disruptions, and these results may have
implications for partial ligamentous disruption in this age
cohort. In a recent study by Lamar and colleagues,4 10 of
13 patients were successfully treated with thermal shrinkage of the ACL in partial tears involving less than 50%
of the native ligament. Indelli and colleagues42 reported
that 96% of knees in their series were normal or near
normal (IKDC A/B) after using thermal modification for
partial ACL tears, with only 1 failure at 2-year follow-up.
We do not perform thermal shrinkage for partial ACL
tears, as recent reports have demonstrated a high failure
rate as well as graft complications in patients with native
and reconstructed ligaments, respectively.43,44 Our current
strategy is anatomical reconstruction aimed at restoring
the damaged portion of the native ACL. This strategy
is similar to the technique reported by Buda and colleagues45: using hamstring autograft in augmentation
surgery to reconstruct the damaged portion of the ACL
in partial ACL deficiency. At final, 5-year follow-up, 45
of their 47 patients (95.7%) had good or excellent results,
with no recurrence of ligamentous laxity. Although our
techniques are similar in principle, we use femoral bone
tunnels (used in standard ACL reconstructions) instead
of the over-the-top technique of Buda and colleagues. Our
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Orthopedics®
approach reflects the anatomical principle of reconstructing the damaged bundle, AM or PL, which may be all that
is necessary to restore knee function and stability (Figures
3–6). For patients with symptomatic instability and partial
tears involving both bundles, a standard single-bundle
ACL reconstruction can be performed with anatomical
placement of the graft.
Summary
In sports medicine, diagnosis and treatment of partial
tears of the ACL continue to be difficult. Understanding
ACL anatomy has helped to clarify these injuries and
has been implemented as a treatment strategy recently.
Although the history and physical examination of patients
with partial ACL tears may be similar to those of patients
with complete ligamentous disruption, often the symptoms are vague and the physical examination not confirmatory of the injury. MRI, though useful, has not been
as sensitive as arthroscopy in detecting partial ACL tears,
but the addition of oblique and coronal sequences and
the detection of a bone bruise can significantly improve
diagnostic accuracy.
Treatment of partial tears continues to be controversial. Although natural history studies have demonstrated satisfactory knee function at follow-up, significant
declines in activity level and return to preinjury activity
level have been noted by most investigators. In addition,
in most series, risk for progression to complete rupture
has been reported to be almost 40%. A treatment program that can be tailored to individual needs and activity levels is warranted. Neuromuscular proprioceptive
training has shown promise in preventing ACL injury
and may be useful in preventing progression to complete
rupture. Functional knee bracing is another option for
patients who want to forgo surgical intervention. For
patients who continue to experience instability or who
progress to complete rupture, augmentation surgery and
standard ACL reconstruction remain viable treatment
alternatives.
Authors’ Disclosure Statement
The authors report no actual or potential conflict of interest in relation to this article.
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